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Job Objective: A brief overview of the position.
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- Provides administrative support for Patient Safety and Quality Improvement team; coordinates projects related to organizational and regulatory requirements, including The Joint Commission, California Department of Public Health, the Centers for Medicare and Medicaid Services, and other accreditation and certification entities
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Reports to
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- Director-Quality/Patient Safety Officer
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Supervises
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- N/A
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Ages of Patients
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- N/A
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Blood Borne Pathogens
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- Minimal/ No Potential
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Qualifications
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Education
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- Required: Associate’s degree if hired after January 1, 2025
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Licensure/Certification
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- N/A
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Experience
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- Required: Two (2) years of professional business and customer service experience
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- Preferred: Healthcare experience
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Essential Responsibilities
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- Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
- Performs administrative duties for Director of Quality Improvement and Patient Safety Officer, Quality Managers and Quality Improvement and Patient Safety staff.
- Coordinates all hospital system licensure requests, de-licensing, hospital annual license, and other requests as needed.
- Manages the triage process for quality of care and service concerns received from internal or external entities in written and/or verbal complaints, and involves appropriate leadership staff in Service Recovery, as necessary.
- Liaison for phone communication with Quality Improvement staff, physicians, patients, families and in-house contacts.
- Responsible for mail daily, attaching appropriate reference materials when pertinent and forwarding to appropriate recipient.
- Establishes and maintains effective files for Director of Quality Improvement and Patient Safety Officer, and Quality Manager, including personnel records.
- Works with QI Staff to prepare and maintain current reports and documentation for Joint Commission, CDPH, and CMS Continued Survey Preparedness, including managing updates and reviewing documentation related to regulatory compliance.
- Collaborates with Infection Preservationist (IP) to enter Surgical Site infection and manage data entry processes for NHSN (CDC mandatory reporting site) accurately and to meet deadlines from CDC; completes reporting forms for Public Health; reports infection data to regulatory bodies; maintains spreadsheets and internal tracking with graphs for IP Committee and Quality Council IPs; sends out questionnaires to surgeons quarterly to query surgical site infections.
- Performs other duties as assigned.
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Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
